Rehabilitation

The increased survival rate of breast cancer patients has made the need for rehabilitation for women with mastectomies obvious. It should be an essential part of the therapy programs coordinated and carried out by an interdisciplinary team made up of doctors, nurses, physiotherapists, social workers, patients and theirRELATIVES.

Until recently, the medical focus was on the cure more than on the rehabilitation afterwards. But as with other chronic disease (cancer is a chronic disease) all the problems involved must be dealt with.

The cancer survivor’sQUALITY OF LIFE has become an issue recently. Not that this a new concept. It just emphasizes that a patient’s medical care doesn’t begin and end with diagnosis and therapy: it also has to be focused on preventing and treating the possible post treatment physical effects. Functional limitations, or pain that increases dependence and reduce well-being, thus undermining the patient’s quality of life, cannot be accepted as a ‘lesser evil’.

In the holistic treatment of the woman who has had a mastectomy, physiotherapy has an important role to play, as much in preventingcomplications as treating those that occur and maintaining the improvements that have been attained.

PHYSIOTHERAPY AS PREVENTION

Once the immediate postoperative problems are overcome, the physical rehabilitation programs begin, with active and passive movements, and after the stitches are removed, more complex exercises can begin.

In the first phase recovering mobility in the shoulder is essential .

The physiotherapist should become in involved as soon as possible, showing the patient the proper exercises within 24 to 48 hours after surgery, always with the authorization of the surgeon or the gynecologist who has carried out the operation.

The following should be recommended:

Breathing exercises

> Deep abdominal and chest breathing breath in and breath out slowly

Gentle and progressive movements of the shoulder in all the planes of articulation, without straining it.

> Flexion, extension, and internal and external rotation. At first you can use your other arm to help, then progressively make the movements more active.

Movements of the other joints of the arm (elbow, wrist and hands)

> Flexion and extension of the elbow.

> Flexion, extension and rotation of the wrist

> Opening and closing the hand.

> Moving the fingers in all possible directions

After being released from hospital you must continue exercising your arm at home, in order to recover its functions, and also add some other gentle physical exercises. for example, going for a walk every day.

In this phase you can gradually add stretches for your arm to prevent retractions in the shoulder which would limit its functions.

At first you might be afraid of stretching too much because of the scar, so you will have to keep the scar flexible by massage and a suitable oil or cream, and gradually you’ll gain confidence.

The following are some of the exercises that you can do:

> Lift your arm in front of you opening and closing your hand in order to stimulate lymphatic circulation.

> Active exercises done with both extremities: raising and lowering your shoulders and rotating them forward and backward.

> Raising your arms.

> Combined exercises

– raise your hand to the back of your neck
– touch your ear with the hand on the opposite side by passing it over your head
– fasten your bra
– clasp your hands behind the back of your neck
– clasp your hands at waist level behind your back
– while facing a wall lift your arm raising your fingers on the wall to one side of your body (not directly in front of you)
– trace circles on the wall in a clockwise and counterclockwise direction.
– raise your arm over your head and holding that position flex and extend your wrist

Your physiotherapist will supervise your exercises, checking to make sure you do them correctly, in order to avoid problems that may be caused by doing them incorrectly, and to evaluate your progress.

You need to look for the right moment to do the exercises, not do them perfunctorily, paying attention to your posture and movement, to the position of the rest of your body, and the effects of each movement. If necessary, you can do the exercises in front of a mirror.

Knowing WHAT exercises you need to do, HOW they should be done and at WHAT intensity is very important, as is being monitored.

You need to keep your arm in the correct resting position in order to prevent endema.

> If you are lying in bed and feel your arm is tired, you can put it on a pillow.

> When you are sitting down you should keep your arm on a pillow and raised above the level of your heart

Being active is essential. As the European Code against Cancer says: KEEP MOVING!

Many women feel fatigue, which theyRELATE to the chemotherapy. Some of these drugs do cause varying degrees of muscular atrophy, and this is a factor to bear in mind. However, there is not much that can be done to prevent fatigue if it does occur, since chemotherapy is essential in many stages of cancer

But fatigue is a complex set of symptoms with multiple causes. Two of them can be avoided. They are not exercising and being overweight. These two factors together are largely responsible for the symptoms of fatigue. A proper diet should keep you from becoming overweight.

Gentle and constant physical activity can prevent muscular atrophy and help to maintain an acceptableQUALITY OF LIFE.

The level and variety of physical activities proposed can be gradually increased, depending on the what kind of shape the patient was in to begin with. going for longer walks, preferably inCONTACT with nature (the countryside, the beach), swimming, tai-chi

If moving the shoulder is painful and/or limited in range, outpatient physiotherapy should be continued until full recovery.

A woman with breast cancer should be physically active, and the more the better, except if there are limitations produced by the illness. But this is normally not the case in most of the initial stages.

Most activities can be done, keeping in mind hygiene practices and the recommendations for preventing lymphedema (swelling of the arm) one of the main complications after surgery.

Lymphedema is edema caused by the restriction of a lymph vessel.

You must be able to recognize the situations that could involve risk and keep them in mind, since the risk is chronic.

> Wear appropriate, loose-fitting underwear
> Avoid clothes with tight sleeves
> Don’t let your arm hang off the bed while sleeping at night
> Don’t wear rings, bracelets or watches that squeeze the arm on the affected side
> You should carry your handbag on the opposite side of the surgical site.
> Don’t carry heavy objects
> Don’t do tasks that require keeping your arms raised
> Activities that require making prolonged efforts with your arm should be avoided ironing, using the mop, cleaning windows, sports that involve repeated movements of your arm
> Don’t have your blood pressure taken in the arm on the side that has been operated on

Since the skin is one of the main entries for infections and there is a immune deficiency in that area, you need to take special care of the skin covering it.

> Use neutral soap daily, dry the skin well and hydrate it with suitable products.
> Avoid injury or infections burns, cuts, scratches from pets.
> Don’t puncture the skin for any reason Acupuncture should not be applied to the arm on the side of the operation.
> Avoid excessive heat on the arm (be careful with the oven, the iron…) Be careful with exposure to the sun.

You need to measure the circumference of your arm in three places, following the instructions of your physiotherapist: at your wrist, around your biceps, and in the middle of your forearm. This will allow you to detect if there is any change the moment it happens, since any increase indicates the beginning of lymphedema.

Appropriate post surgical physiotherapy, integrating into ADL (activities of daily life) exercises for the arm affected by the operation , plus following the recommendations given can prevent future complications from appearing.

PHYSIOTERAPY IN THE TREATMENT OF COMPLICATIONS

Both surgery and radiotherapy can cause complications that require physiotherapy. Many of these complications are the result of inadequate treatment.

Lymphedema is the most common complication, but is not the only one; there can also be a limitation of the movement of the shoulder, and in some cases the retraction of the pectoral muscle due to radiotherapy.

Treatment

1. for lymphedema

2. for the shoulder

3. for the scar if there are adhesions

1. LYMPHEDEMA

Contributing factors:

> Removal of axillary lymph nodes
> Local fibrosis caused by radiotherapy or scarring
> Reduction of regional muscular activity
> The particular patient’s lymphatic system (not all women who have had their axillary lymph nodes removed and have had physiotherapy have had lymphedema).
> Being overweight does not increase the possibility of lymphedema, but if it does appear it usually has a greater volume.

The appearance and the location of lymphedema depends on the lymph nodes removed and the amount of conducts that have been replaced.

It can appear immediately or years after surgery.

Treatment

If lymphedema is diagnosed, treatment must begin immediately to avoid it worsening. This treatment must be given regularly in order to be efficient. There are phases:

The aim of MLD is to eliminate the fluid build-up and to stimulate the superficial lymphatic circulation.

Manuel Lymphatic Drainage must bePERSONALIZED, adapted to each patient, and needs to be continually adapted to the state of the lymphedema as it changes in response to the treatment.

Causing pain or irritation of the skin should be avoided.

Bandage

The purpose of the bandage is to increase the absorption of lymph fluid, reduce the flow of the fluid in the veins, and increase the return.

A bandage will be applied after each session of MLD.

It needs to be adapted to each patient.

It must be correctly fitted, it shouldn’t cause discomfort, and it must stay in place while the arm is being used.

The entire limb is bandaged, from the fingers (leaving the finger tipsFREE) to the armpit.

There are different kinds of bandages. The physiotherapist will decide which is the best one to use depending on the type of lymphedema.

In the first stage of therapy the physiotherapist must show the patient how to put the bandage on, since she will have to do this in the second stage.

In some situations neither MLD nor a bandage are recommended.

> If there are general or local infections (first the infection must be treated).
> When there are symptoms of thrombosis or thrombophlebitis in the arm of the affected side, since moving the arm could dislodge the clot and cause problems in other organs.
> If there are skin lesions
> …

Exercises with a bandage

The patient should do exercises while wearing the bandage in order to stimulate the lymph system.

These can be the same exercises recommended for after surgery.

Once the lymphedema is reduced, maintenance therapy is very important.

B- Maintenance therapy phase

Outpatient therapy will continue once or twice a week, and the exercises prescribed should be done at home every day.

In this stage the bandage is usually substituted by an adapted elastic compression sleeve. This sleeve may be different for each patient but it is important to wear it all day.

Post radiotherapy fibrosis is frequent, with functional impotence or limited movement of the arm on the same side as the surgical intervention.

Muscle strength and range of movement can be reduced, above all in abduction and external rotation.

Arm movement may be painful.

Therapy is based on:

> Measures to reduce pain
> Passive movements
> Active movements

Long term lack of mobility can cause retraction in the joint. This might begin with not using the affected arm in order to avoid mild pain, but in the long run the situation becomes chronic and needs to be treated.

3. Therapy for the scar

The main complications that can occur are: adhesions and keloids These are treated with massage and manipulation of the scar.

Improving the therapy carried out by experts, increasing the use of less mutilating therapy and preventative planning will help reduce undesirable complications (if the efficiency of these measures are definitely demonstrated).

The active involvement of the patient in her treatment is absolutely necessary since she has the central role in the therapy.